BELLEVIEW HEIGHTS ALZHEIMER'S SPECIAL CARE CENTER

A licensure complaint, prompted by #CO42309, was completed on 6/3/26. Deficiencies were cited.

Based on record review and interview, the residence failed to promote resident safety by not implementing interventions detailed in the care plan to reduce falls, and failed to detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs for one former (#7) and one current (#3) of four residents sampled for care plans. Specifically, Former Resident #7 was recognized as a potential fall risk from an initial fall assessment, dated 11/20/25, and the care plan developed from the assessment included a fall intervention for a motion sensors, that was to be on at night and/or when Former Resident #7 was in their room. Former Resident #7 fell on 5/13/26 at approximately 9:00 p.m., and was discovered by staff to have crawled from her room to the hallway and was yelling. Former Resident #7 sustained a skin tear on her right elbow, and was in extreme pain in her right leg/knee. It was discovered that Staff working on 5/13/26 had intentionally turned off the motion sensor while assisting Former Resident #7 to bed at approximately 8:30 p.m, and had not turned the motion sensor back on once Former Resident #7 was in bed. Subsequently, Former Resident #7 fell and had to crawl to the hallway from inside her bedroom and yell out for assistance while with injuries of a skin tear and pain to her right leg/knee. Specifically, Resident #3 fell approximately eight times from March to May 2026. Two of the times Resident #3 fell as staff were assisting her in the shower or in the bathroom. On 3/5/26 Resident #3 fell, bumped her head and was sent to the emergency department. On 4/11/26 Resident #3 took herself to the restroom and fell on her right side and hit her head. She sustained a skin tear to her elbow and was unable to move her elbow and she was sent to the emergency department. On 5/3/26 Resident #3 took herself to the bathroom and she fell. On 5/6/26 staff found a bruise on Resident #3's bottom. On 5/15 and 5/20/26 Resident #3 fell in her room. On 5/28/26 Resident #3 fell in the common area bathroom, hit her head and complained of pain. An external service provider note, dated 6/1/26 read Resident #3 had a bruise on her bottom and right knee from a recent fall. Resident #3's care plan did not include recommendations made by the external therapist provider or how staff were to promote safety awareness when Resident #3 took herself to the restroom. Findings include:1. Former Resident #7 was admitted to the residence on 11/19/26, diagnoses included dementia and unspecified joint pain. A care plan, dated 11/17/2025 read in part: Former Resident #7 had a fall intervention, being a motion sensors, that was to be on at night and/or when Former Resident #7 was in their room. A progress note, dated 5/13/26, read in part: Former Resident #7 was heard by a qualified medication administration personnel (QMAP) down the hallway, Former Resident #7 was discovered on the floor in the hallway on her bottom scooting on the floor. Former Resident #7 had a skin tear on her right elbow, and she had extreme pain in her right leg/knee. A corrective action document, dated 5/14/26 read in part: On 5/13/26 at approximately 9:00 p.m., Former Resident #7 was reported to be yelling and was checked on by a caregiver who contacted the QMAP, being Staff #1. Former Resident #7 was observed on floor in the hallway near her apartment after Former Resident #7 had rolled out of bed and crawled to the hallway after a fall. The motion sensors were not on in Former Resident #7's apartment to notify staff Former Resident #7 had been moving around her bed prior to falling. The corrective action document concluded that it was the responsibility of all care staff to ensure motion sensors were on for each resident who was in their apartments alone. A corrective action document, dated 5/14/26 read in part: On 5/13/26 at approximately 9:00 p.m., Former Resident #7 was reported to be yelling. Former Resident #7 was observed on floor in the hallway near her apartment after Former Resident #7 had rolled out of bed and crawled to the hallway after a fall. The motion sensors were not on in Former Resident #7's apartment to notify staff Former Resident #7 had been moving around her bed prior to falling. Staff #4 was the caregiver assigned to Former Resident #7. The corrective action document concluded that it was the responsibility of all care staff to ensure motion sensors were on for each resident who was in their apartments alone. a. InterviewsOn 6/2/26 at 12:30 p.m., Staff #2 said the motion sensors only beeped at the nursing station and not in the resident rooms or anywhere else. Staff #2 said there was a button at the front door of every room that staff pushed when they entered to acknowledge entering a resident room and a second button to push when leaving a room to activate the sensor. On 6/3/26 at 10:00 a.m., the administrator said she spoke with Staff #1 and Staff #4 regarding the 5/13/26 progress note for Former Resident #7 and why was Former Resident #7 yelling. The administrator said both Staff #1 and Staff #4 said the motion sensor for Former Resident #7 was turned off while Staff #4 was in the room helping with care and had not been turned back on after Staff #4 had left the room. The administrator said both staff had been written up and it was her [administrator] expectation that motion sensors remain on at all times regardless of if staff are in the room assisting or not. On 6/3/26 at 10:30 a.m., Staff #4 said she had helped Former Resident #7 to bed on 5/13/26 between 8:30 p.m. and 9:00 p.m., and that Staff #1 had turned off the motion sensor alarm for Former Resident #7 at the main controls at the nursing station. Staff #4 said it's not uncommon for Staff #1 to turn off motion sensor alarms from the nursing station to not hear them go off while staff are providing resident care in the evenings. Staff #4 said moments after she had helped Former Resident #7 and was in with another resident she [Staff #4] received a call on the walkie talkie from Staff #1 that Former Resident #7 had fallen and was yelling. Staff #4 said Staff #1 had not turned the motion sensor alarm back on at the nursing station for Former Resident #7's the evening of 5/13/26. On 6/3/26 at 11:00 a.m., Staff #1 said she had turned off the motion sensor alarm for Former Resident #7 while Staff #4 assisted her [Former Resident #7] into bed on the evening of 5/13/26. Staff #1 said it was standard practice for her to turn the motion sensor alarms off at the nursing station while residents were being provided evening care before bed, otherwise, the alarms went off while staff were moving around in the rooms. Staff #1 said Staff #4 had not told her [staff #1] that Former Resident #7 was in bed so she [Staff #1] had not turned the motion sensor alarm back on for Former Resident #7's room. Staff #1 said she was sitting at the nursing station when she her Former Resident #7 yelling out and upon arrival it appeared Former Resident #7 had crawled to the hallway from her bed. 2. Resident #3 was admitted to the residence on 2/1/23 with diagnoses including Alzheimer's disease, history of falling. Progress notes for Resident #3 in March, April and May 2026 revealed the following:On 3/5/26 Resident #3's bedroom motion sensor was alarming so staff went to her room and found her on the floor. Resident #3 had a bump on her head. Emergency responders were notified and she was sent to the emergency department for evaluation. On 4/11/26 at approximately 4:00 p.m., Resident #3 was walking to the restroom with her wheelchair in front of her. She lost her balance and fell on her right side. Resident #3 hit her head and sustained a skin tear on her elbow. Resident #3 was unable to move her elbow so emergency responders were notified and transported Resident #3 to the emergency department for evaluation. 4/19/26: Staff were assisting Resident #3 in the shower. Staff left the room to get something and that is when Resident #3 fell. On 4/27/26 staff were walking with Resident #3 when she lost her balance and fell. 5/3/26 at approximately 4:00 p.m., a staff member heard a loud noise coming from the common area bathroom. Resident #3 said she lost her balance and fell. On 5/6/26: Staff noticed a bruise on Resident #3's bottom. On 5/15/26 Resident #3's bedroom motion sensor was alarming so staff found Resident #3 seated on the floor. Resident #3 said she fell out of bed. On 5/20/26 at approximately 8:30 a.m., Resident #3's bedroom motion sensor was alarming and staff found her seated on the floor. On 5/28/26 at approximately 4:30 p.m., Resident #3 fell in the common area bathroom. Resident #3 hit her head and complained of pain. Emergency responders were notified. An emergency department after visit summary, dated 3/5/26 read Resident #3 fell and sustained a head injury. External therapy provider notes for May and June 2026 revealed the following:On 5/13/26 an external service provider (ESP) recommended staff assist Resident #3 to the bathroom every two hours. On 5/18/26 the ESP reminded staff to ensure they were assisting Resident #3 in the bathroom. On 5/20/26 the ESP noted a skin tear on Resident #3's left arm. The ESP added a recommendation for Resident #3 to be taken to the restroom between 9:00 p.m. and 10:00 p.m. On 6/1/26 the ESP said Resident #3 had a purple bruise on her bottom and right knee from a recent fall. A care plan for Resident #3, last updated on 5/16/26 read for staff to increase rounding on each shift, ensure she is in the middle of her bed and to assist with toileting throughout the shift. "Effective fall interventions are limited and inconclusive." There was no written evidence of staff assisting Resident #3 to the bathroom every two hours, nor was there any evidence of individualized approaches to address and promote safety when Resident #3 was trying to take herself to the common area bathroom in the early afternoon. a. InterviewsOn 6/2/26 at 12:25 p.m., Staff #6 said to prevent Resident #3 from falling she was told to keep Resident #3 out of her room and to turn on the motion sensor when she was in her room. On 6/2/26 at 12:50 p.m., Staff #5 said she was trained to keep an eye on Resident #3 as she recently had a change in her baseline. She added when Resident #3 was outside of her room she kept an eye on her and all residents who were identified as being a fall risk. She added Resident #3 went to the common area bathroom without anyone noticing. On 6/2/26 at 1:00 p.m., Staff #4 said Resident #3 fell because she used the bathroom too much and said to prevent falls she ensured the motion sensors were turned on when she was in her room. She added, she would ask her if she needed to use the bathroom. On 6/2/26 at approximately 2:30 p.m., Staff #2 said to prevent Resident #3 from falling she kept Resident #3 in the common area and kept an eye on her and encouraged her to stay in her wheelchair. She added if she was in her room she ensured the motion sensor light was on. Staff #2 said she was never told by anyone how to prevent falls that she did what she felt was best for Resident #3. On 6/3/26 at 7:42 a.m., Staff #7 said the interventions in place to prevent Resident #3 from falling were ensure the motion sensor was on in her bedroom. She added that Resident #3 often would take herself to the bathroom without anyone noticing. Staff #7 said after the falls in May 2026 she was told to keep an eye on Resident #3. On 6/3/26 at 9:43 a.m., Staff #8 said after Resident #3 fell in May 2026 there were no changes in regards to fall prevention other than for staff to assist her with her activities of daily living and to check on her more often. On 6/3/26 at 10:30 a.m., the administrator said she expected the care plans for residents to be individualized and she expected the care plan to be updated when a resident fell or had a change in their baseline status. The administrator said she expected staff to be able to speak to what personalized approaches were in the care plans, especially around fall prevention. The administrator added she had not noticed the trend in Resident #3's falls when she experienced three falls in the early afternoons in the common area bathrooms. She added she also expected the ESP recommendations to be entered into Resident #3's care plan and would expect staff to be able to speak to those interventions.

Based on interviews and record review, the residence failed to coordinate resident care services with an external service provider for one of four residents sampled for coordination of care (#2). Findings Include:1. Resident #2 was admitted to the residence on 1/19/26 with a diagnosis of Parkinson's disease. A progress note, dated 3/23/2026, read: "Spoke with the resident's primary care physician (PCP) regarding his high risk for falls, non-compliance with using his walker, toe walking, not sleeping at night, and poor appetite. Medication review with the PCP, physical therapy (PT) order, and lab work was recommended. PCP agrees with the recommendation and will order PT and labs."There was no evidence in Resident #2's record to show if PT was ordered by the practitioner or if a medication review was conducted. 2. InterviewsOn 6/2/26 at 3:00 p.m., the health service coordinator (HSD) said she was not aware of Resident #2 receiving PT or labs indicated in the March of 2026 progress note and would reach out to the PCP regarding the order for PT and labs. On 6/3/26 at 10:00 a.m., the administrator said the residence was responsible for following up on coordination for care.

Based on observation and interviews, the residence failed to ensure qualified medication administration personnel (QMAP) did not pre-pour medications or use masking or deceiving techniques while concealing medication in food, affecting five residents sampled for medication (#1-#5). (Cross-reference U1530)Findings Include:1. Observation and interviewa. On 6/2/26 at 7:30 a.m., a drawer within a portable medication cart contained three small, clear, plastic cups, labeled with either a resident room number or resident name. Staff #1, who was the QMAP working from the medication cart said the cups contained medication for Resident's (#2-#5). Staff #1 said she had Pre-poured medication for Resident's #3 thru #5 earlier in morning when she [Staff #1] saw the residents sitting up front near the nursing station, but got distracted and had not given them. Staff #1 said she did not recall the exact time she had dispensed each medication for each resident. Staff #1 said the medications for Resident #2 were dispensed the previous day by the health services director (HSD). Staff #1 said she was aware pre-pouring medications was not allowed. b. On 6/2/26 at approximately 7:40 a.m., Staff #1 dispensed and crushed medication for Resident #1, retrieved jelly from the kitchen and mixed the jelly into the crushed medication. Staff #1 proceeded to hand the resident a spoon with the jelly medication mixture and stated, "here's some jelly" after Resident #1 did not take the spoon Staff #1 put the jelly medication mixture on a piece of toast and handed it to Resident #1, who then took a bite. Resident #1 stated, "what is that" and Staff #1 stated "it's jelly toast". Staff #1 said Resident #1 often declined taking medications if the crushed medication were presented to her in a small medication cup. Staff #1 stated she [Staff #1] told Resident #1 it was jelly and not medication. Staff #1 said mixing the crushed medication in jelly and not informing Resident #1 it was her medication was how she [Staff #1's] routinely delivered Resident #1's medications. 2. InterviewsOn 6/2/26 at 8:30 a.m., the administrator said it was not acceptable for QMAPs to pre-pour medications or to be deceptive and mask medications during medication administration. On 6/2/26 at approximately 9:00 a.m., HSD said it was not acceptable for medications to be pre-poured. The HSD said she had not pre-poured any medication for Resident #2 and was not aware who had.

Based on observation, record review and interviews, the residence failed to have an authorized practitioner order for a prepared medication, affecting one of five sample Resident #2. (Cross-Reference U1528 and U1604)Findings Include:On 6/2/26 at 7:30 a.m., a drawer within a medication cart had a small clear plastic cup displaying the name of Resident #2 and containing two white, oblong pills without any marking on the pills. Staff #1 said the pills were Tylenol that the health service director (HSD) had added to the cup on the previous day for if Resident #2 requested them. However, Resident #2 did not have an order for Tylenol nor was Tylenol indicated on the medication administration record (MAR). On 6/2/26 at approximately 9:00 a.m., the HSD retrieved the plastic cup displaying Resident #2's name and identified the two oblong white pills as tylenol, however, the HSD was unable to find a corresponding order for Tylenol for Resident #2. The HSD said only medication that had been ordered by an authorized practitioner should be prepared or administered to a resident. On 6/2/26 at approximately 10:00 a.m., the administrator said only medications ordered by an authorized practitioner should be administered to a resident.

Based on observation and interviews, the residence administered stock medications, affecting three of five sample residents (#2, #5 and #6). (Cross-Reference U1604). Findings Include:1. Observation On 6/2/26 at 7:30 a.m., an observation of the medication cart being used by Staff #1 revealed the following items:Small clear plastic cup displaying the name of Resident #2 and 25mg= ½ Trazodone hand written on it contained one half of a circular white pill, two quartered pieces of a round white pill and two white oblong pills said to be Tylenol by Staff #1. A tube of Diclofenac Sodium Topical Gel with the "Community Use" hand written on it. An observation of a second medication cart locked in a medication room, labelled overflow revealed the following:A plastic divider displaying the name of Resident #5 with a bubble pack where the right side corner had been cut off and on the left remaining corner was a sticker that read Aspirin chewable 81 Mg Tablet. On 6/3/26 at 7:20 a.m., Staff #1 retrieved a bubble packet of medication with the right side corner cut off and displaying in hand writing on the left side the name of Resident #6 and 500 mg acetaminophen. Staff #1 dispensed the medication into a plastic medication cup and gave it to Resident #6 who ingested it. 2. InterviewsOn 6/2/26 at 7:30 a.m., Staff #1 said the Trazodone for Resident #2 had belonged to a former resident who passed away last month and that the resident service director kept it to use for Resident #2. On 6/3/26 at 7:20 a.m., Staff #1 said the medication she dispensed and gave to Resident #6 had also belonged to a former resident and was saved by the health service director (HSD) to use for the purpose of overstock medication. On 6/2/26 at 10:00 a.m., the HSD said it was not ideal to use overstock medications but she felt it better to have an overstock to use than for residents to go without. On 6/2/26 at 10:30 a.m., the administrator said there should not be stock medications available to administer to residents.

Based on record review and interview, the residence failed to ensure that the administrator and the qualified medication administrator personnel (QMAP) supervisor audited the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records, affecting 30 current residents. (Cross reference U1530 and U1594)Findings include:1. Record reviewOn 6/2/26 at approximately 10:00 a.m., a request for the last quarterly medication audit was made to the administrator. However it was not received. 2. InterviewOn 6/2/26 at approximately 10:00 a.m., the administrator said the last medication audit, involving herself and the QMAP supervisor, was completed in January of 2026. The administrator said she was aware of the regulation and that an audit should have been completed in March of 2026.

A survey, prompted by #CO39834 and #CO40652, was conducted on 4/15/26. No deficiencies were cited.

A revisit survey was completed on 1/15/25 for all previous deficiencies cited on 8/8/24. The facility is in compliance with all deficiencies that were cited.

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A revisit survey was completed on 1/15/25 for all previous deficiencies cited on 8/8/24. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 1/15/25 for all previous deficiencies cited on 8/8/24. The facility is in compliance with all deficiencies that were cited.

A relicensure survey with complaints #CO35664 and #CO36669 was completed on 8/8/24. Deficiencies were cited.

Based on record review and interview the residence failed to have written documentation of first aid and cardiopulmonary resuscitation (CPR) certification in staff personnel files, affecting nine of 11 staff members (#5-#7, #9, and #11-#15). Findings include:On 8/7/24 at approximately 8:00 a.m., first aid certifications for all staff were requested from the administrator. However, no current first aid certifications were provided for Staff #5-#7, #9, and #11-#15. On 8/7/24 at approximately 10:30 a.m., the administrator stated Staff #5-#7, #9, and #11-#15 had completed the CPR and first aid certification class in May 2024. However, the residence did not pay the fees for the class to the training company who in turn did not provide the residence with the staffs' CPR and first aid certification documentation. On 8/7/24 at approximately 1:30 p.m., The first aid certification program manager confirmed the attendance and certification of Staff #5-#7, #9, and #11-#15. She confirmed the residence had not paid the registration fees for the training class and the first aid certification cards were being withheld until payment was received. On 8/8/24 at 9:20 a.m., the administrator stated she was aware of the requirement to have documentation of first aid certification for at least one staff member on site at all times. The administrator explained she thought the former business office manager had paid the invoice and discovered after his termination on 6/14/24 the invoice had not been paid.

Based on observation and interview, the residence failed to ensure there was a list of all staff who had a current certification in first aid and cardiopulmonary resuscitation (CPR) in a visible location and readily available at all times, affecting 49 current residents. Findings include:An environmental tour on 8/7/24 from approximately 7:00 a.m. to 12:00 p.m., revealed no evidence of a visible list of staff with current CPR and first aid certifications. On 8/7/24 at approximately 1:30 p.m., a list of CPR/first aid certified staff was provided. However, the list was dated the day of the onsite investigation and was not updated to include Staff #8-#10, who were CPR and first aid certified. On 8/7/24 at 7:39 a.m., Staff #7 stated she had not noticed a list of CPR and first aid certified staff in a visible location and readily available at all times within the residence. On 8/7/24 at 8:30 a.m., the business office manager stated she had a list of staff who were CPR and first aid certified that she was editing; however, it was only posted in the business office and she had never seen a list -visible and readily available in the secure environment of the residence. On 8/8/24 at approximately 9:30 a.m., the administrator stated she was aware of the requirement for a list of staff with current certifications in CPR and first aid list to be visible, readily available, and updated to include current certified staff; however, they have had increased staff turnover so they did not update a list and place it in a visible location because it must have "slipped."

Based on record review and interview, the residence failed to develop and implement a visitation policy which described any restriction or limitation necessary to ensure the health and safety of residents, staff and visitors, affecting 49 current residents. Findings include:On 8/7/24 at approximately 8:00 a.m., the residence's visitation policy was requested but not provided. On 8/8/24 at 9:30 a.m., the administrator stated she was unaware of the regulation updated 1/1/24, requiring the residence to develop and implement a visitation policy.

Based on record review and interview, the residence failed to develop and implement an involuntary discharge grievance policy that complied with Section 25-27-104.3, C.R.S., affecting 49 current residents. Findings include:On 8/7/24 at approximately 8:00 a.m., the residence's involuntary discharge grievance policy was requested but not provided. On 8/8/24 at 9:30 a.m., the administrator stated she was unaware of the regulation updated 1/1/24 requiring the residence to develop and implement an involuntary discharge grievance policy.

Based on record review and interview, the residence failed to develop and implement defined procedures to prevent the spread of influenza, affecting 49 current residents. Findings include:On 8/7/24 at approximately 8:00 a.m., the residence's policy and procedure to prevent the spread of influenza was requested, but not provided. On 8/8/24 at 9:30 a.m., the administrator stated she was unaware of the regulation update, effective 1/1/24, requiring the residence to develop and implement a defined policy and procedure to prevent the spread of influenza.

Based on record review and interview, the residence failed to comply with authorized practitioner's orders associated with medication administration, affecting three of five sample residents whose medications were reviewed (#14, #16 and #17). Findings include:1. Residence PolicyThe residence's Medication Administration policy, dated 7/15/24, read in part: "The administration of medication shall be as ordered by the resident's (practitioner)."2. Resident #14 was admitted to the residence on 7/10/24 with a diagnosis of Alzheimer's disease. PradaxaA written practitioner's order, dated 7/11/24, directed the residence to administer pradaxa 150 mg twice daily. However, the July and August 2024 electronic medication administration records (eMARs) read the residence failed to administer the medication for a total of eight missed doses. Potassium chlorideA written practitioner's order, dated 7/11/24, directed the residence to administer potassium chloride 10 MEQ twice daily. However, the July 2024 eMAR read the residence failed to administer the medication for a total of eight missed doses. ZenpepA written practitioner's order dated 7/11/24, directed the residence to administer zenpep 5,000-24,000 unit capsule three times daily. However, the July 2024 eMAR read the residence failed to administer the medication for a total of four missed doses. Additionally, the residence failed to comply with practitioner's orders for the following medications after Resident #14 was admitted to the residence on 7/10/24:Acetaminophen 500 mg twice dailyAmlodipine Besylate 10 mg dailyEscitalopram Oxalate 10 mg dailyMelatonin 5 mg at bedtimeMirtazapine 15 mg at bedtimeOmeprazole 40 mg twice dailyOn 8/7/24 at 3:03 p.m., the health services director (HSD) stated that Staff #7 documented that she administered potassium on the morning on 7/15/24, even though the residence failed to have the medication in stock and staff could not have administered it. On 8/7/24 at 3:05 p.m., the health and wellness nurse (HWN) stated staff did not administer any of Resident #14's medications when the resident was admitted the evening of 7/10/24. The HWN stated some of Resident #14's medications were delivered on the evening of 7/11/24; however, the residence did not have some of the medications in stock until 7/12 and 7/13/24 and were not administered until then. On 8/7/24 at 3:34 p.m., Resident #14's family member stated she did not administer any of Resident #14's medications to her. Resident #14's family member stated Resident #14 had pill bottles filled with medications from her home; however, she did not provide the medications to the residence until 7/12/24. On 8/7/24 at 3:39 p.m., Resident #14's external service provider stated the external service company did not administer any of Resident #14's medications to her the week of her admission to the residence. The external service provider stated they did not provide Resident #14's pradaxa, adding that the practitioner would discontinue the medication. The external service provider stated the residence did not have Tylenol, amlodipine, and escitalopram in stock until the evening of 7/11/24; she added that the residence did not have the rest of the resident's medication, other than the pradaxa, in stock until 7/12/24. On 8/8/24 at approximately 9:30 a.m., the administrator stated she expected the residence to comply with practitioner's orders. 3. Evidence revealed similar deficient practice for Residents #16 and #17.

Based on record review, observation and interview, the residence failed to ensure that qualified medication administration persons (QMAPs) were trained in and applied nationally recognized protocols for basic infection control and prevention when preparing and administering medications, affecting three of seven sample residents (#15, #18, and #19) whose medications were administered. Findings include:The undated medication administration policy, read in part, "The licensed nurse and the qualified medication aide will administer medications by completing the following steps: Wash hands thoroughly according to community policy."On 8/7/24 at approximately 7:45 a.m., Staff #5 started medication administration for Resident #15 without washing or sanitizing her hands. Staff #5 touched her keys, the medication cart, medication packs, laptop and the medication cups. Staff #5 poured the medications into the medication cup and closed the medication cart. Staff #5 administered the medications to Resident #15. On 8/7/24 at 7:55 a.m., Staff #5 prepared medications for Resident #18 and touched her keys, the medication cart, medication packs, laptop and the medication cups. Staff #5 poured the medications into the medication cup. Staff #5 then used hand sanitizer and administered the medications to Resident #18. On 8/7/24 at approximately 8:10 a.m., Staff #5 used hand sanitizer then touched her keys, the medication cart, medication packs, laptop and the medication cups. Staff #5 poured Resident #19's medications into her hand then placed the medications into the medication cup. Staff #5 put the medication packs into the medication cart, then took one medication out of the medication cup and broke it in half using her fingers. Staff #5 then administered the medications to Resident #19. On 8/7/24 at 8:41 a.m., Staff #5 retrieved the overstock bottle of Memantine HCL 5 mg for Resident #15 from the medication room. Staff #5 carried the medication to the medication cart, pulled a medication cup, poured the medication into the cap of the medication bottle and dropped the medication on the floor. Staff #5 picked up the medication from the floor and placed the medication into the medication cup, then administered the medication to Resident #15. On 8/8/24 at 9:20 a.m., the administrator said she expected staff to wash or sanitize their hands before each medication administration. The administrator stated she expected staff to destroy any medication after it had been dropped on the floor.

Based on record review and interview, the residence failed to, on a quarterly basis, audit the controlled substance list, medication error reports and medication disposal records, affecting 49 current residents. Findings include:On 8/7/24 at 9:11 a.m., the administrator provided medication audits of electronic medication administration records (eMARs) for three quarters prior to the onsite visit. However, there was no evidence the administrator audited controlled substance lists, medication error reports and medication disposal records. On 8/8/24 at approximately 9:30 a.m., the administrator stated she was unaware of the requirement to conduct quarterly medication audits of the controlled substance lists, medication error reports and medication disposal records. The administrator stated she thought she only was required to audit eMARs.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 2.12.2.2 Each facility shall assign at least one (1) staff member responsible for the site management of the facility ' s Infection Prevention and Control Program and training. This individual shall be responsible for the following: Completing an infection prevention and control training from a nationally-recognized provider or the Department ' s training program within two (2) weeks of appointment/designation that meets the following requirements based on facility type. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.14.29 All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident ' s room location, any known allergies, and the name and telephone number of the resident ' s authorized practitioner.(C) Each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident.

A relicensure revisit was completed on 8/8/24 for the previous deficiencies cited on 9/20/23. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/24.

Based on interviews and record review, the residence failed to comply with conditions imposed by the department on the license, affecting 49 current residents. Findings include:The department completed a re-licensure survey on 6/20/23. The residence failed to implement a fall management plan and was cited tag Q1180 at a C level for harm. The department determined the residence violated statutory and regulatory requirements necessitating that the department impose an intermediate condition on 11/27/23. The residence was required to pay a civil fine of $1000 by 12/27/23. The residence did not appeal the intermediate condition. Review of the department database revealed the residence had not yet paid the civil fine as of 8/8/24. A department representative confirmed that the residence had not paid the civil fine as of 8/8/24. On 8/8/24 at 9:30 a.m., the administrator stated she was aware of the fine and assigned the previous business office manager to pay the fine. She was unaware that the residence failed to pay the fine associated with the last survey.

Based on observation and interview, the residence failed to ensure there was a list of all staff who had a current certification in first aid and cardiopulmonary resuscitation (CPR) in a visible location and readily available at all times, affecting 49 current residents. This deficiency was previously cited during a state licensure survey on 9/20/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:An environmental tour on 8/7/24 from approximately 7:00 a.m. to 12:00 p.m., revealed no evidence of a visible list of staff with current CPR and first aid certifications. On 8/7/24 at approximately 1:30 p.m., a list of CPR/first aid certified staff was provided. However, the list was dated the day of the onsite investigation and was not updated to include Staff #8-#10, who were CPR and first aid certified. On 8/7/24 at 7:39 a.m., Staff #7 stated she had not noticed a list of CPR and first aid certified staff in a visible location and readily available at all times within the residence. On 8/7/24 at 8:30 a.m., the business office manager stated she had a list of staff who were CPR and first aid certified that she was editing; however, it was only posted in the business office and she had never seen a list -visible and readily available in the secure environment of the residence. On 8/8/24 at approximately 9:30 a.m., the administrator stated she was aware of the requirement for a list of staff with current certifications in CPR and first aid list to be visible, readily available, and updated to include current certified staff; however, they have had increased staff turnover and the deficiency had not been corrected since it must have "slipped."

A complaint revisit was completed on 8/8/24 for all previous deficiencies cited on 6/20/23. Deficiencies were cited. Tag 1604 was not cited in the previous event; however, the deficiency was included in the previous event's informational 9999 tag. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/24.

Based on record review and interview, the residence failed to comply with authorized practitioner's orders associated with medication administration, affecting three of five sample residents whose medications were reviewed (#14, #16 and #17). This deficiency was cited previously during a state licensure complaint on 6/20/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence PolicyThe residence's Medication Administration policy, dated 7/15/24, read in part: "The administration of medication shall be as ordered by the resident's (practitioner)."2. Resident #14 was admitted to the residence on 7/10/24 with a diagnosis of Alzheimer's disease. PradaxaA written practitioner's order, dated 7/11/24, directed the residence to administer pradaxa 150 mg twice daily. However, the July and August 2024 electronic medication administration records (eMARs) read the residence failed to administer the medication for a total of eight missed doses. Potassium chlorideA written practitioner's order, dated 7/11/24, directed the residence to administer potassium chloride 10 MEQ twice daily. However, the July 2024 eMAR read the residence failed to administer the medication for a total of eight missed doses. ZenpepA written practitioner's order dated 7/11/24, directed the residence to administer zenpep 5,000-24,000 unit capsule three times daily. However, the July 2024 eMAR read the residence failed to administer the medication for a total of four missed doses. Additionally, the residence failed to comply with practitioner's orders for the following medications after Resident #14 was admitted to the residence on 7/10/24:Acetaminophen 500 mg twice dailyAmlodipine Besylate 10 mg dailyEscitalopram Oxalate 10 mg dailyMelatonin 5 mg at bedtimeMirtazapine 15 mg at bedtimeOmeprazole 40 mg twice dailyOn 8/7/24 at 3:03 p.m., the health services director (HSD) stated that Staff #7 documented that she administered potassium on the morning on 7/15/24, even though the residence failed to have the medication in stock and staff could not have administered it. On 8/7/24 at 3:05 p.m., the health and wellness nurse (HWN) stated staff did not administer any of Resident #14's medications when the resident was admitted the evening of 7/10/24. The HWN stated some of Resident #14's medications were delivered on the evening of 7/11/24; however, the residence did not have some of the medications in stock until 7/12 and 7/13/24 and were not administered until then. On 8/7/24 at 3:34 p.m., Resident #14's family member stated she did not administer any of Resident #14's medications to her. Resident #14's family member stated Resident #14 had pill bottles filled with medications from her home; however, she did not provide the medications to the residence until 7/12/24. On 8/7/24 at 3:39 p.m., Resident #14's external service provider stated the external service company did not administer any of Resident #14's medications to her the week of her admission to the residence. The external service provider stated they did not provide Resident #14's pradaxa, adding that the practitioner would discontinue the medication. The external service provider stated the residence did not have Tylenol, amlodipine, and escitalopram in stock until the evening of 7/11/24; she added that the residence did not have the rest of the resident's medication, other than the pradaxa, in stock until 7/12/24. On 8/8/24 at approximately 9:30 a.m., the administrator stated she expected the residence to comply with practitioner's orders. 3. Evidence revealed similar deficient practice for Residents #16 and #17.

Based on record review and interview, the residence failed to, on a quarterly basis, audit the controlled substance list, medication error reports and medication disposal records, affecting 49 current residents. Findings include:On 8/7/24 at 9:11 a.m., the administrator provided medication audits of electronic medication administration records (eMARs) for three quarters prior to the onsite visit. However, there was no evidence the administrator audited controlled substance lists, medication error reports and medication disposal records. On 8/8/24 at approximately 9:30 a.m., the administrator stated she was unaware of the requirement to conduct quarterly medication audits of the controlled substance lists, medication error reports and medication disposal records. The administrator stated she thought she only was required to audit eMARs.

A relicensure survey was completed on 9/20/23. Deficiencies were cited.

Based on observation, record review and interview, the residence failed to place in a visible location a list of all staff who had current certification in first aid and/or cardiopulmonary resuscitation (CPR), so that the information was readily available to staff at all times, affecting 42 current residents. Findings include:On 9/20/23 at approximately 7:30 a.m., an environmental tour of the residence revealed there was no list of all staff who had current certification in first aid and/or CPR in a visible location so the information was readily available to staff at all times. On 9/20/23 at approximately 9:34 a.m., the business office manager (BOM) stated he had a list of CPR and first aid certified staff on his computer. The BOM acknowledged there was not a list of CPR and first aid certified staff posted in the residence. On 9/20/23 at 9:50 a.m., the BOM provided 10 CPR and first aid certifications for the 10 staff members that had current certifications in first aid and/or CPR. On 9/20/23 at 3:40 p.m., Staff #4 stated she had worked at the residence two years and stated she had never seen a list of CPR and first aid certified staff and was unaware where to find it. On 9/20/23 at 6:02 p.m., the administrator stated she did not have a list of CPR and first aid certified staff in a visible location in the residence, since she was not aware it was required.

Based on observation, record review and interview, the residence failed to establish a fall management program which included detailing in each resident's care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting one of two sample residents who fell in the secure environment (#9). Specifically, Resident #9 had a fall on 7/17/23 and sustained a cut on his forehead. On 8/6/23 Resident #9 sustained a fall with a cut over his right eyebrow and bruising to his left side. On 8/17 and 8/19 Resident #9 fell again without injury. However, the residence failed to update Resident #9's care plan (which was the same as the residence's assessment) to include individualized approaches necessary to address the resident's fall risk after Resident #9's first fall at the residence on 7/17 and after his additional falls on 8/6, 8/17 and 8/19/23. As a result, Resident #9 fell again on 8/23 and hit his head, on 8/27 with a quarter size red area on his forehead and on 8/29 with a bruised nose and the care plan still had not been updated. Findings include:1. Residence policyThe residence's Fall Policy, dated 1/15/20, read in part: "should a resident experience a fall, staff will provide or arrange for necessary emergency care, and will follow up with necessary service plan (care plan) updates."2. Resident #9 was admitted to the residence on 6/19/23, with a diagnosis of Alzheimer's Disease. The residence's assessment (which was also the residence's care plan), dated 6/19/23, read Resident #9 had no falls in the last year, was independent with transfers and required no assistive mobility devices. There were no fall interventions in place in the residence's care plan. A progress note, dated 7/17/23, read Resident #9 leaned downwards, fell asleep, fell down and sustained a cut on his forehead. A late-entry progress note, dated 8/7/23, read that on 8/6/23 Resident #9 had a fall after running into the wall, and hit his right eyebrow. A progress note, dated 8/8/23, read Resident #9 had bruises on the left side of his body from his previous fall. A progress note, dated 8/17/23, read Resident #9 fell around 10:30 p.m. with no apparent injuries. A progress note, dated 8/19/23, read Resident #9 had a fall while he was standing because he fell asleep. A progress note, dated 8/23/23, read Resident #9 had an unwitnessed fall and was holding his head. External hospice and the family member for Resident #9 were notified. A progress note, dated 8/27/23, read Resident #9 was found on the floor and knocked his head against the wall. A small quarter sized red area on his forehead and no other bumps or injuries were observed. A progress note, dated 8/29/23, read Resident #9 had a fall and was found laying on his side on the floor and his nose was bruised. No other injuries. However, the residence's care plan had not been updated for Resident #9 after his first fall at the residence on 7/17/23, or after any of the above falls on 8/6, 8/8, 8/17, 8/19, 8/23, 8/17 and 8/29/23 to include individualized approaches necessary to address fall risks related to deficits in strength and balance. A second quarterly care plan, dated 9/14/23 read the resident was at risk for falls due to cognitive impairment, required assistance and cueing with transfers, and had no assistive devices. However, the care plan did not include individualized interventions related to Resident #9 falling forward or include that the resident had a walker; however, refused to use it. On 9/20/23 at 3:41 p.m., no fall interventions were observed for Resident #9, or in the resident's room. 3. InterviewsOn 9/20/23 at 3:37 p.m., Staff #2 stated he was not aware of any fall interventions in place for Resident #9. Staff #2 further stated Resident #9 seemed to fall as a result of leaning forward too much. On 9/20/23 at 3:40 p.m., Staff #4 stated Resident #9 was on external hospice services and had no specific fall interventions in place. Staff #4 stated Resident #9 fell due to leaning forward. On 9/20/23 at 3:43 p.m., the memory care director (MCD) stated Resident #9 required monitoring due to his frequent falls, and required external hospice services. The MCD further stated Resident #9 would lean forward and staff were to verbally correct him to sit or stand up straight so he would not fall forward. The MCD stated she was responsible for updating care plans and stated the assessment was the same as the care plan. The MCD further stated she was unaware the care plan needed to be updated after each fall to include individualized fall interventions. She further acknowledged the care plan should have been updated after Resident #9's first fall to reflect he was a fall risk. On 9/20/23 at 4:55 p.m., the family member for Resident #9, stated the resident had not fallen prior to being admitted to the residence. The family member for Resident #9 stated he suffered a heart attack when he was first admitted and would fall whenever he stood up too quickly. The family member further stated she was unaware of any interventions put in place other than Resident #9's walker for ambulation which the resident refused to use. On 9/20/23 at 6:02 p.m., the administrator stated the only fall interventions Resident #9 had in place was that he required external hospice services. The administrator stated she was unaware of the requirement for care plans to be updated with individualized interventions after each fall.

Based on interviews and record review, the residence failed to hold regular family council meetings at least quarterly, affecting 42 current residents in the secure environment. Findings include:On 9/20/23 at 7:15 a.m., the last three quarters of family council meetings were requested. However, no such documentation was provided. On 9/20/23 at 9:59 a.m., the memory care director (MCD) stated family council meetings were not provided because they were conducted by the former life enrichment director (LED) and she was unable to obtain access to the documentation she had for the meetings. The MCD further stated the meetings had not been quarterly since she could not remember that last time one was held. On 9/20/23 at 4:55 p.m., the legal representative for Resident #9 stated she had never received any invitation for a family council meeting and had never attended such a meeting. On 9/20/23 at 5:29 p.m., the legal representative for Resident #12 stated she had never received any invitation for a family council meeting and had never attended such a meeting. On 9/20/23 at 6:02 p.m., the administrator stated she was aware of the requirement for quarterly family council meetings in the secured environment, and stated a meeting was not held in the last quarter. The administrator stated the former LED left her position at the residence in June 2023 and she had conducted the meetings. The administrator stated the last family council meeting was in May 2023; however, stated she was unable to find documentation of that meeting.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.12.9 The comprehensive assessment shall be updated for each resident at least annually and whenever the resident ' s condition changes from baseline status. 14.29 All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident ' s room location, any known allergies, and the name and telephone number of the resident ' s authorized practitioner. (A) The medication administration record shall reflect the name, strength, dosage, and mode of administration of each medication, the date the order was received, the date and time of administration, any special considerations related to administration, and the signature or initial of the person administering the medication. (C) Each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident. 14.33 The assisted living residence shall ensure that the resident ' s authorized practitioner and resident ' s legal representative are promptly notified of:(B) A resident ' s pattern of refusal;(D) Any observed or reported unfavorable reactions to medications;(F) Medication errors that affect the resident. 18.8 Resident records shall contain, but not be limited to, the following items:(D) Progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident ' s physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident ' s changing needs;(1) The assisted living residence shall require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed, or was reported to them. 25.10 In addition to the information required for a resident care plan at Part 12.10, the care plan for each resident in a secure environment shall include the following:(A) A description of the resident ' s wandering patterns and known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact.

A licensure complaint, prompted by #CO32086, was completed on 6/20/23. Deficiencies were cited.

Based on record review, interviews, and observations the residence failed to be responsible for complying with authorized practitioner's orders associated with medication administration, affecting six of six and one former sample residents (#1, #2, #3, #4, #5, #6, #7). Findings include: 1. Residence Policy and References: a. The residence's Medication Administration Policy, dated 01/15/20, read in part: "The Health Services Director will be notified when prescribed medications are not available to be administered at the scheduled time. The Health Services Director will be responsible for investigating the reason medication(s) are not available, and taking corrective actions to ensure the medication is available as prescribed". b. The residence's Medication Administration Policy, dated 1/15/20, read in part: "Non-controlled drug inventory for residents contracted with pharmacy will be monitored by the qualified staff during medication administration. The Residence or the Resident's responsible party will be notified by the licensed nurse with the inventory levels are within seven (7) days of depletion to allow time for the refill medication(s). The Licensed nurse will notify the dispensing pharmacy of the need to refill medication(s). The Residence responsible party will be responsible for ensuring the medication is delivered personally or through an agreement with the dispensing pharmacy"..."The Health Services Director will be notified when prescribed medications are not available to be administered at the scheduled time. The Health Services Director will be responsible for investigating the reason medication(s) are not available, and taking corrective actions to ensure the medication is available as prescribed."c. The Resident Agreement, dated 4/1/21, read in part: "The community reserves the right to order your medications from the contracted pharmacy, and you will be responsible for the cost of those medications." d. The Mayo Clinic states that Lisinopril is to lower blood pressure. "If blood pressure is not treated, it can cause serious problems such as heart failure, blood vessel disease, stroke, or kidney disease."Mayo Clinic (May 1, 2023), Lisinopril, Proper Use, retrieved from: https://www.mayoclinic.org/drugs-supplements/lisinopril-oral-route/proper-use/drg-20069129e. The Mayo Clinic states "Take Divalproex exactly as directed by your doctor. Do not take more of it, do not take it more often, and do not take it for a longer time than your doctor ordered. To keep blood levels constant, take this medicine at the same time each day and do not miss any doses."Mayo Clinic (June 1, 2023) Divalproex, Proper Use, retrieved from: https://www.mayoclinic.org/drugs-supplements/divalproex-sodium-oral-route/proper-use/drg-20072886f. The Mayo Clinic states to take Carvedilol "exactly as directed and that you keep your appointments with your doctor even if you feel well. If high blood pressure is not treated, it can cause serious problems such as heart failure, blood vessel disease, stroke, or kidney disease."Mayo Clinic (June 1, 2023), Carvedilol, Proper Use, retrieved from: https://www.mayoclinic.org/drugs-supplements/carvedilol-oral-route/proper-use/drg-200675652. Resident #4 was admitted to the residence on 11/15/22 with diagnosis of Unspecified Dementia without behavioral disturbance.a. Carvedilol A written practitioner order, dated 1/24/22, directed the residence to administer carvedilol tab 3.123 mg, by mouth two times a day for hypertension. (No parameters listed on orders) The residence's May 2023 medication administration record (MAR) for Resident #4 read carvedilol, was not administered due to Blood Pressure parameters less than 140. The practitioner orders did not list parameters on blood pressure. Doses were not administered on 5/7 p.m., 5/8 a.m., 5/8 p.m., 5/9 a.m., 5/18/23 p.m. There were a total of five missed doses.b. Entresto A written practitioner order, dated 1/24/22, directed the residence to administer entresto tab 49/51 mg tab, by mouth two times a day (Hold for systolic blood pressure below 80). The residence's May 2023 Medication Administration Record (MAR) for Resident #4 read entresto tab 49/51 mg, was not administered due to blood pressure below 140. The practitioner order directed the residence to hold for systolic below 80. Documentation read below 140 on 5/7, 5/8 a.m., 5/8 p.m., 5/9 a.m., 5/11 a.m., There were a total of 5 missed doses. c. ProstagenixA written practitioner order, dated 5/17/23, directed the residence to administer prostagenix, two capsules by mouth one time a day. The residence's May and June 2023 MARs for Resident #4 read prostagenix, was not available for administration due to "Waiting on Family" on 5/1-5/12, 5/19-5/23, 5/26-5/30, 6/2, 6/7, 6/8, 6/11, 6/12, 6/13, 6/17, 6/18, 6/19/23. There were a total of 31 missed doses.d. DocusateA written practitioner order, dated 5/17/23, directed the residence to administer docusate sod cap 200 mg, by mouth one time a day. The residence's June 2023 MAR for Resident #4 read docusate was not available for administration on 6/13/23 There was a total of one missed dose. 3. Resident #2 was admitted to the residence on 2/16/23, with diagnoses of dementia, depression, and Alzheimer's. a. QuetiapineA written practitioner order, dated 4/17/23, directed the residence to administer quetiapine 25 mg, three tablets, twice daily. The residence's April 2023 MAR for Resident #2 read quetiapine was not available for administration on 5/8/23 p.m., 6/18/23 p.m. There were a total of two missed doses. b. DonepezilA written practitioner order, dated 1/31/23, directed the residence to administer donepezil 10 mg, one tablet daily. The residence's June 2023 MAR for Resident #2 read donepezil was not available for administration on 6/16, 6/17/23. There were a total of two missed doses.c. LevothyroxineA written practitioner order, dated 1/31/23, directed the residence to administer levothyroxine 25 mcg, one tablet daily. The residence's June 2023 MAR for Resident #2 read levothyroxine was not available for administration on 6/9, 6/10, 6/11/23. There were a total of three missed doses. 4. Resident #6 was admitted to the residence on 1/3/22 with diagnoses including Hypomagnesemia, Hypertension, Hypothyroidism, Major depressive disorder. a. AcetaminophenA written practitioner order, dated 2/15/22, directed the residence to administer acetaminophen 325 mg, two tablets three times daily. The residence's June 2023 MAR for Resident #6 read acetaminophen was not available for administration on 5/21 and 5/20/23. There were a total of two missed doses.b. Alendronate A written practitioner order, dated 6/12/22, directed the residence to administer alendronate 70 mg, one tablet every seven days. The residence's May and June 2023 MARs for Resident #6 read alendronate was not available for administration on 5/4 and 6/8/23. There were a total of two missed doses.c. DonepezilA written practitioner order, dated 11/22/22, directed the residence to administer donepezil 10 mg, one tablet at bedtime. The residence's May and June 2023 MARs for Resident #6 read donepezil was not available for administration on 5/1-5/12, 5/16, 5/21-5/30, 6/1- 6/2, 6/4-6/7, 6/9-6/15/23. There were a total of 35 missed doses.d. LevothyroxineA written practitioner order, dated 11/22/22, directed the residence to administer levothyroxine 50 mcg, one tablet in the morning. The residence's June 2023 MAR for Resident #6 read levothyroxine was not available for administration on 5/1-5/3, 5/6 -5/12, 5/16 -5/20, 5/22 -5/31, 6/1- 6/15/23. There were a total of 36 missed doses.e. MemantineA written practitioner order, dated 3/1/22, directed the residence to administer memantine 10 mg, one tablet twice daily. The residence's June 2023 MAR for Resident #6 read memantine was not available for administration on 6/1- 6/15/23. There were a total of 15 missed doses.f. SertralineA written practitioner order, dated 11/22/22, directed the residence to administer sertraline 50 mg, one tablet daily. The residence's May and June 2023 MARs for Resident #6 read sertraline was not available for administration on 5/1-5/5, 5/9-5/11, 5/15-5/17, 5/21-5/23, 5/27-5/29,6/1-6/3, 6/6-6/15/23. There were a total of 29 missed doses.g. TramadolA written practitioner order, dated 3/15/22, directed the residence to administer tramadol 50 mg, 1/2 tablet twice dailyThe residence's June 2023 MAR for Resident #6 read tramadol was not available for administration on 5/13 a.m. 5/15 p.m. to 6/1 a.m., 6/1 p.m. to 6/20 a.m., 6/20/23 p.m. There were a total of 74 missed doses. 5. Resident #1 was admitted to the residence on 12/8/22 with diagnoses of cognitive issues and dementia. a. Gabapentin A written practitioners order dated 1/5/23, directed the residence to administer gabapentin 100 mg, one capsule by mouth at bedtime. The residence's February 2023 MAR for Resident #1 read gabapentin was not available for administration on 2/10 p.m., 2/21 p.m., 2/22 a.m., 2/22 p.m. There were a total of four missed doses. b. Vitamin DA written practitioners order dated 2/23/23, directed the residence to administer vitamin D 2,000 U (50 mcg), once daily. The residence's February and March 2023 MAR for Resident #1 read vitamin D was not available for administration on 2/27, 2/28, 3/1, 3/7/23. There were a total of four missed doses. c. PotassiumA written practitioners order dated 1/11/23, directed the residence to administer potassium cl er 10 Meq, twice a day. The residence's March and April 2023 MAR for Resident #1 read potassium cl er was not available for administration on 3/3 a.m., 3/3 p.m., 3/4, a.m., 3/4 p.m., 3/5 a.m., 3/5 p.m., 4/5 p.m., 4/6 a.m., 4/11 a.m., 4/11/23 p.m. There were a total of 10 missed doses. d. Theratears Opth Solution A written practitioners order dated 2/23/23, directed the residence to administer theratears opth solution, two drops in left eye two times a day. The residence's January MAR for Resident #1 read theratears opth solution was not available for administration on 1/12/23. There was a total of one missed dose. e. Aspirin A written practitioners order dated 1/11/23, directed the residence to administer aspirin 81 mg, chew one tablet by mouth a day for Prophylaxis. The residence's January MAR for Resident #1 read aspirin was not available on 1/7, 1/9, 1/11/23. There were a total of three missed doses. f. Preservision A written practitioners order dated 2/9/23, directed the residence to administer Preservision AREDS Caps, one capsule by mouth two times a day. The residence's April 2023 MAR for Resident #1 read Preservision was not available for administration on 4/11a.m.- 4/11/23 p.m. There were a total of two missed doses. 6. Resident #7 was admitted to the residence on 11/15/21 with diagnosis of Psychotic disorder with delusions, Anxiety disorder, Hypertension, and Hypokalemiaa. Lisinopril A written practitioner order, dated 3/16/23, directed the residence to administer Lisinopril 20 mg, one tablet a day for hypertension. The residence's April, May and June 2023 MARs for Resident #7 read Lisinopril was not available for administration medication due to medication not available on 4/20-4/30, 5/23-6/12. There were a total of 24 missed doses.b. MagnesiumA written practitioner order, dated 1/26/23, directed the residence to administer magnesium 400 mg, one tablet one time a day. The residence's April, May and June 2023 MARs for Resident #7 read magnesium was not available, waiting for clarification, or awaiting delivery from pharmacy on 4/15/23-6/20/23. There were a total of 65 missed doses. On 6/20/23 at 2:27 p.m., the pharmacy stated the magnesium 400 mg for Resident #7 had been discontinued because the medication was no longer listed on the practitioner's order list the pharmacy had. However, there was no evidence of a discontinue order at the facility. On 6/20/23 at approximately 3:00 p.m., the Memory Care Director (MCD) stated that she was aware of recent practitioner changes. However, was unaware that medication for Resident #7 had been discontinued by the pharmacy on the last practitioner order. c. AtenololA written practitioner order, dated 1/10/23, directed the residence to administer atenolol 25 mg, one tablet in the morning. The residence's May 2023 MAR for Resident #7 read atenolol was not available for administration on 5/25/23. There was a total of one missed dose. 7. Resident #3 was admitted to the residence on 9/2/22 with diagnosis of Unspecified Dementia without behaviors.a. PantoprazoleA written practitioner order, dated 10/4/22, directed the residence to administer Pantoprazole 20 mg, daily. The residence's May 2023 MARs for Resident #3 read Pantoprazole was not administered due to resident sleeping on 5/3/23. There was a total of one missed dose.b. Timolol A written practitioner order, dated 9/20/22, directed the residence to administer Timolol 0.25%, one drop in each eye daily. The residence's May 2023 MAR for Resident #3 read Timolol was not administered due to resident sleeping on 5/3/23. There was a total of one missed dose. c. AspirinA written practitioner order, dated 9/20/22, directed the residence to administer aspirin 81 mg, daily. The residence's May 2023 MAR for Resident #3 read aspirin was not administered resident sleeping on 5/3/23 There was a total of one missed dose.d. Potassium A written practitioner order, dated 9/20/22, directed the residence to administer potassium 20 Meq, daily. The residence's May 2023 MARs for Resident #3 read potassium was not administered due to resident sleeping or medication was not available for administration on 5/3, 5/5, 5/25/23. There were a total of three missed doses.e. Vitamin B12 A written practitioner order dated 9/20/22, directed the residence to administer vitamin B12 1000 mcg, daily. The residence's May 2023 MARs for Resident #3 read vitamin B12 was not administered due to resident sleeping or medication not available on 5/3/23, 5/23-5/25. There were a total of four missed doses.f. Vitamin D3 A written practitioner order dated 9/20/22, directed the residence to administer vitamin D3 1000 mcg, daily. The residence's May 2023 MARs for Resident #3 read vitamin D3 was not administered due to resident sleeping on 5/3/23. There was a total of one missed dose. 9. Resident #5 was admitted to the residence on 6/1/22 with diagnosis of Unspecified Dementia.a. AcetaminophenA written practitioner order dated 3/30/23, directed the residence to administer acetaminophen 325 mg, two tablets every 6 hours. The residence's May 2023 MAR for Resident #5 read acetaminophen 325 mg was not administered due to medications not available on 5/22 to 5/24 12:00 a.m., 5/29/23 a.m. There were a total of six missed doses. b. DivalproexA written practitioner order, dated 3/30/23, directed the residence to administer divalproex 250 mg, twice daily. The residence's May 2023 MARs for Resident # 5 read divalproex 250 mg was not available for administration on 5/24/23 5:00 p.m. There was a total of one missed dose. 10. Interviews:On 6/20/23 at 11:10 a.m. the Health Services Coordinator (HSC) stated held meant not available when documenting in the MAR. On 6/20/23 at 2:50 p.m., the HSC indicated that practitioners visit the residence on a weekly basis. Nevertheless, she attributed the need for clarification and documentation of medications to issues with mislaid, misplaced, or missing fax documentation. Additionally, she pointed out that medication discrepancies may be the result of night staff QMAPs inadvertently placing medication in the wrong location. Furthermore, she speculated that recent change in resident practitioners might also be a contributing factor. On 6/20/23 at 3:00 p.m., the Memory Care Director (MCD) stated that residents have the right to refuse medications. However, in the medication administration policy it reads QMAPs need to wake the resident to attempt to give them the medication. She was unaware staff had been marking resident sleeping. On 6/20/23 at 3:00 p.m., the MCD acknowledged her awareness of medication errors and understood that audits were to be conducted on a quarterly basis. However, she attributed missing medications to the pharmacy or QMAP's failure to thoroughly check the overflow area. On 6/20/23 at approximately 4:00 p.m., the administrator stated she was aware medications may have been missed due to a change in practitioners.

Based on interview and record review, the residence failed to ensure each qualified medication administration person (QMAP) accurately documented each medication administration event at the time the event was completed for each resident, affecting two of six sample residents (#1, #3). Findings:1. Record Review 2. Resident #1 was admitted to the residence on 12/8/22 with diagnoses of cognitive issues and dementia. a. Clopidogrel A written practitioner order, dated 3/30/23, directed the residence to administer clopidogrel 75 mg, one tablet one time a day. The residence's April 2023 MAR for Resident #1 read clopidogrel "Held" on 4/28, 4/29, and 4/30/23; however, Resident #1 was hospitalized at this time and not at the residence. b. Quetiapine 50 mgA written practitioner order, dated 1/27/23, directed the residence to administer quetiapine 50 mg one tablet at bedtime for dementia with behaviors. The residence's April 2023 MARs for Resident #1 read quetiapine "Held" on 4/27, 4/28, 4/29 and 4/30/23; however, Resident #1 was hospitalized at this time.c. Gabapentin A written practitioners order dated 1/5/23, directed the residence to administer gabapentin 100 mg one capsule by mouth at bedtime. The residence's April 2023 MAR for Resident #1 read gabapentin "Held" or "Not needed" on 4/27, 4/28, 4/29, and 4/29/23; however, Resident #1 was hospitalized at this time. d. PotassiumA written practitioners order dated 1/11/23, directed the residence to administer potassium 10 Meq, twice a day. The residence's April 2023 MAR for Resident #1 read Potassium "Held" or "Not needed" on 4/27, 4/28, 4/29 and 4/30; however, Resident #1 was hospitalized at this time.e. Aspirin A written practitioners order dated 1/11//23, directed the residence to administer aspirin 81 mg chew, one tablet by mouth a day. The residence's April MAR for Resident #1 read Resident #1 read aspirin "Held" on 4/28, 4/29, and 4/30/23; however, Resident #1 was hospitalized at this time.f. Carvedilol A written practitioners order dated 1/5/23, directed the residence to administer carvedilol tablet 25 mg, two times a day. The residence's April 2023 MAR for Resident #1 read carvedilol "Held" or "Not needed" on 4/27, 4/28, 4/29 and 4/30/23; however, Resident #1 was hospitalized at this time.g. FurosemideA written practitioner order, dated 1/24/22, directed the residence to administer furosemide 40 mg, tab one tab for edema. The residence's April 2023 MAR for Resident #1 read furosemide "Held" on 4/28, 4/29 and 4/30/23; however, Resident #1 was hospitalized at this time. h. Lisinopril A written practitioners order dated 2/9/23, directed the residence to administer Lisinopril 20 mg, one tablet by mouth every twelve hours, take along with COREG.The residence's April 2023 MAR for Resident #1 read Lisinopril 20 mg, "Held" on 4/28 a.m. and 4/29/23; however, Resident #1 was hospitalized at this time. i. Lidocaine Patch A written practitioner's order dated 1/5/23, directed the residence to administer Lidocaine Patch 4%, apply one patch topically to back one time a day. The residence's April 2023 MAR for Resident #1 read, Lidocaine Patch 4% "Held" on 4/28 and 4/30/23; however, Resident #1 was hospitalized at this time.j. Isosorbide Mono ER A written practitioner order, dated 1/5/23, directed the residence to administer isosorbide mono er 60 mg, one tablet by mouth one time a day. The residence's April 2023 MAR for Resident #1 read, isosorbide mono "Held" on 4/28, 4/29 and 4/30/23; however, Resident #1 was hospitalized at this time.k. Fluticasone Nasal Spray A written practitioner order, dated 1/5/23, directed the residence to administer fluticasone nasal spray 50 mg, one spray once daily. The residence's April 2023 MAR for Resident #1 read, fluticasone nasal spray "Held" on 4/28, 4/29 and 4/30/23; however, Resident #1 was hospitalized at this time.l. Primidone A written practitioner order, dated 1/27/23, directed the residence to administer primidone 50 mg, one tablet two times a day. The residence's April 2023 MARs for Resident #1 read, primidone 50 mg, "Held" or "Not needed" on 4/27, 4/28, 4/29 a.m., 4/29, and 4/30/23; however, Resident #1 was hospitalized at this time. m. Sertraline A written practitioner order, dated 1/11/23, directed the residence to administer sertraline 100 mg, one tablet one time a day. The residence's April 2023 MAR for Resident #1 read, Sertraline 100 mg "Held" on 4/28, 4/29 and 4/30/23; however, Resident #1 was hospitalized at this time. n. Theratears Opth Solution A written practitioners order dated 2/23/23, directed the residence to administer therstears opth solution, two drops in left eye two times a day. The residence's April MAR for Resident #1 read Theratears "Held" or "Not needed" on 4/27, 4/28, 4/29 and 4/30/23; however, Resident #1 was hospitalized at this time.o. Preservision A written practitioners order dated 2/9/23, directed the residence to administer Preservision AREDS Caps, one capsule by mouth two times a day. The residence's April 2023 MAR for Resident #1 read Preservision AREDS two Caps "Held" or "Not needed" on 4/27, 4/28, 4/29 and 4/30/23; however, Resident #1 was hospitalized at this time.p. Vitamin DA written practitioners order dated 2/23/23, directed the residence to administer vitamin D 2,000 U (50mcg), once daily. The residence's April 2023 MAR for Resident #1 read vitamin D 2,000 "Held" on 4/28, 4/29 and 4/30/23; however, Resident #1 was hospitalized at this time. 3. Resident #3 was admitted to the residence on 9/2/22 with diagnosis of Unspecified Dementia without behaviors.a. LevothyroxineA written practitioner order, dated 9/6/22, directed the residence to administer levothyroxine 100 mcg, one tablet daily. The residence's May 2023 MAR for Resident #3 read levothyroxine 100 mcg was "given at hospital" on 5/14/23.b. Escitalopram A written practitioner's order dated 9/6/22, directed the residence to administer Escitalopram tab 5 mg, by mouth at bedtime. The residents May 2023 MAR for Resident #3 read Escitalopram was "given at the hospital" on 5/14/23.c. OlanzapineA written practitioner's order dated 1/16/23, directed the residents to administer olanzapine 5 mg, by mouth one time a day. The residents May 2023 MAR for Resident #3 read Olanzapine was "given at the hospital "on 5/14/23.d. TimololA written practitioner's order dated 9/6/22, directed the residence to administer Timolol OPTH 0.025%, one drop in each eye two times a day. The residents May 2023 MAR for Resident #3 read Timolol was "given at hospital" on 5/14/23.4. Interviews:On 6/20/23 at 11:10 a.m. Health Services Coordinator (HSC) stated held meant not available when documenting in the MAR and did not know why staff were documenting anything on the MAR when the resident was not at the residence.

Based on record review and interview, the residence failed to ensure that the residents authorized practitioner was notified of a resident's pattern of refusal, affecting three of six sample residents (#1, #4, #5). Findings include: 1. Resident #4 was admitted to the residence on 11/15/22 with diagnosis of Unspecified Dementia without behavioral disturbance.a. Carvedilol A written practitioner order, dated 1/24/22, directed the residence to administer carvedilol tab 3.123 mg, by mouth two times a day for hypertension. The residence's May 2023 Medication Administration Record (MAR) for Resident #4 read carvedilol, documented as refused by resident on 5/9 p.m., 5/10 a.m., 5/10 p.m., 5/11 a.m., 5/11 p.m., 5/12 a.m., 12 p.m., 5/13 a.m., 5/13 p.m. to 5/16 a.m., 5/15 p.m., 5/16 a.m. to 5/19 p.m., 5/20 a.m. to 5/24 p.m., and 5/25/23 a.m.b. Entresto A written practitioner order, dated 1/24/22, directed the residence to administer entresto tab 49/51 mg tab by mouth two times a day (Hold for systolic blood pressure below 80). The residence's May 2023 MAR for Resident #4 read entresto tab 49/51 mg, was documented as refused by resident on 5/5 a.m., 5/6 a.m. to 5/11 p.m., 9 p.m., 5/10 a.m., 5/10 p.m., 5/11 a.m., 5/11 p.m. 5/15 p.m., 5/18 a.m., 5/20 a.m., 5/21 a.m., 5/21 p.m., 5/22 a.m., 5/22 p.m., 5/23 a.m., 5/23 p.m., 5/24 p.m., 5/25 a.m., 5/25 p.m., 5/27 a.m. 5/30 p.m., and 5/31/23 p.m. 2. Resident #1 was admitted to the residence on 12/8/22 with diagnoses of cognitive issues and dementia. a. Carvedilol A written practitioners order dated 1/5/23, directed the residence to administer carvedilol tablet 25 mg two times a day. The residence's January and March MARs for Resident #1 read carvedilol was documented as refused by resident on 1/12, 1/28, and 3/7/23.b. Quetiapine A written practitioner order, dated 1/27/23, directed the residence to administer quetiapine 50 mg one tablet at bedtime for dementia with behaviors. The residence's February and March 2023 MARs for Resident #1 read, quetiapine was refused by resident on 2/10 and 3/7/23. c. Sertraline A written practitioner order, dated 1/11/23, directed the residence to administer sertraline 100 mg one tablet one time a day. The residence's March 2023 MAR for Resident #1 read, sertraline was refused by resident on 3/7/23. d. Gabapentin A written practitioners order dated 1/5/23, directed the residence to administer gabapentin 100 mg one capsule by mouth at bedtime. The residence's January, and March 2023 MARs for Resident #1 read gabapentin was refused by resident on 1/12, 1/28 a.m., 1/28 p.m., and 3/7/23. e. PotassiumA written practitioners order dated 1/11/23, directed the residence to administer potassium cl er 10 Meq twice a day. The residence's January and March 2023 MARs for Resident #1 read potassium was documented as refused by resident on 1/12, 1/28 p.m. and 3/7/23.f. Lisinopril A written practitioners order dated 2/9/23, directed the residence to administer Lisinopril 20 mg one tablet by mouth every twelve hours, take along with COREG.The residence's January, February and March MARs for Resident #1 read Lisinopril was documented as refused by resident on 1/28, 2/10 and 3/7/23. g. Trazodone A written practitioners order dated 1/11/23, directed the residence to administer trazodone 50 mg by mouth one time a day at bedtime. The residence's January and February MARs for Resident #1 read, trazodone was documented as refused by resident on 1/28 and 2/10/23. h. Bupropion A written practitioner order, dated 1/5/23, directed the residence to administer bupropion 75 mg, one tablet by mouth one time a day. The residence's March 2023 MAR for Resident #1 read, bupropion was refused by resident on 3/7/23. i. Atorvastatin A written practitioner order, dated 1/11/23, directed the residence to administer atorvastatin 40 mg one tablet by mouth at bedtime. The residence's January and February 2023 MAR for Resident #1 read, atorvastatin was refused by resident on 1/28 and 2/10/23.j. Lidocaine Patch A written practitioner's order dated 1/5/23, directed the residence to administer Lidocaine Patch 4% apply one patch topically to back one time a day. The residence's January, February, and March MARs for Resident #1 read, Lidocaine Patch 4% was documented as refused by resident on 1/30, 2/23, 2/24 and 3/7/23. k. Aspirin A written practitioners order dated 1/11/23, directed the residence to administer aspirin 81 mg chew one tablet by mouth a day. The residence's March MAR for Resident #1 read, aspirin was documented as refused by resident on 3/7/23. l. Preservision A written practitioners order dated 2/9/23, directed the residence to administer Preservision AREDS Caps, one capsule by mouth two times a day. The residence's January and March 2023 MARs for Resident #1 read Preservision AREDS 2 Caps was documented as refused by resident on 1/12, 1/28 and 3/7/23. m. Isosorbide Mono ER A written practitioner order, dated 1/5/23, directed the residence to administer isosorbide mono er 60 mg one tablet by mouth one time a day. The residence's March 2023 MAR for Resident #1 read, isosorbide was refused by resident on 3/7/23.n. Fluticasone Nasal Spray A written practitioner order, dated 1/5/23, directed the residence to administer fluticasone nasal spray 50 mg one spray once daily. The residence's March 2023 MAR for Resident #1 read, fluticasone was refused by resident on 3/7/23. o. Vitamin DA written practitioners order dated 2/23/23, directed the residence to administer vitamin D 2,000 U (50mcg) once daily. The residence's March MAR for Resident #1 read vitamin D was documented as refused by the resident on 3/7/23. p. Famotidine A written practitioner order, dated 1/27/23, directed the residence to administer famotidine 20 mg one tablet by mouth at bedtime. The residence's January and February 2023 MARs for Resident #1 read, famotidine was refused by resident on 1/28 and 2/10/23.q. Theratears Opth Solution A written practitioners order dated 2/23/23, directed the residence to administer theratears opth solution, two drops in left eye two times a day. The residence's January MAR for Resident #1 read theratears opth solution was documented as refused by resident on 1/12 and 1/28/23. 3. Resident #5 was admitted to the residence on 6/1/22 with diagnosis of Unspecified Dementia.a. AcetaminophenA written practitioner order, dated 3/30/23, directed the residence to administer acetaminophen 325 mg two tablets every 6 hours. The residence's May 2023 MAR for Resident #5 read acetaminophen 325 mg was documented as resident refused on 5/1 a.m., 5/3 a.m., 5/4, 5/5, 5/6 ,5/7, 5/9, 5/10, 5/11, 5/16, 5/17, 5/18 a.m., 5/22 p.m., 5/25, 5/26, 5/27, 5/30 and 5/31/23. 4. Interviews On 6/20/23 at 3:24 p.m., family member of Resident #1 stated that they did not contact her regarding medication refusals.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.14.31 The administrator and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Any irregularities shall be investigated and resolved. The results of the audits shall be documented and routinely included as part of the assisted living residence's Quality Management Program assessment and review.